<form id="commonDataFrm">
	<table cellspacing="0" cellpadding="0" class="grid" style="width: 100%">
	    <tbody>
	        <tr>
	            <td style="width: 130px;" class="form_label">{translate}Treatment doctor{/translate}</td>
	            <td class="form_input" style="text-align: left;"><span>{$treatmentDoctorName}</span></td>
	            <td style="width: 130px;" class="form_label">{translate}Pre-diagnosis{/translate}</td>
	            <td class="form_input" style="width: 220px; text-align: left;"><div>{$preDiagnosis}&nbsp;</div></td>
	        </tr>
	        <tr>
	            <td class="form_label">{translate p1=1}Dr/Technician %s{/translate}</td>
	            <td class="form_input" style="text-align: left;">
	                 <select id="technicianId1" name="technicianId1" style="width: 165px;" >
	                 <option value="0" selected="selected">- - {translate}Select{/translate} - -</option>
	                     {html_options options=$techList}
	                 </select>
	            </td>
	            <td class="form_label">{translate}Executed time{/translate}</td>
	            <td class="form_input" style="text-align: left;">
	                <input name="created_{$datePart_0}" id="created_{$datePart_0}" type="text" style="width: 22px;">
	                <input name="created_{$datePart_1}" id="created_{$datePart_1}" type="text" style="width: 22px;">
	                <input name="created_{$datePart_2}" id="created_{$datePart_2}" type="text" style="width: 42px;">
	                <input name="createdTime" id="createdTime" type="text" style="width: 42px;"/>
	                <br/><span class="label" style="width: 21px; color: #AAA;">({$datePart_0}-{$datePart_1}-{$datePart_2} hh:mm)</span>
	            </td>
	        </tr>
	        <tr>
	            <td class="form_label">{translate p1=2}Dr/Technician %s{/translate}</td>
	            <td class="form_input" style="text-align: left;">
	                 <select id="technicianId2"  name="technicianId2" style="width: 165px;" >
	                 <option value="0" selected="selected">- - {translate}Select{/translate} - -</option>
	                     {html_options options=$techList}
	                 </select>
	            </td>
	            <td class="form_label">{translate}Machine{/translate}</td>
	            <td class="form_input" style="text-align: left;"><input id="machine" name="machine" type="text" style="width: 160px;" /></td>                   
	        </tr>
	        <tr class="last">
	            <td class="form_label">{translate}Radiology doctor{/translate}</td>
	            <td class="form_input" style="text-align: left;">
	               <select id="doctorId" name="doctorId" style="width: 165px;" >
	                 <option value="0" selected="selected">- - {translate}Select{/translate} - -</option>
	                     {html_options options=$doctorList}
	                 </select>
	            </td>
	            {if isset($additionalServiceList)}
	            <td class="form_label">{translate}Additional service{/translate}</td>
	            <td class="form_input" id="additionalServiceCol" style="text-align: left;">
	                {html_checkboxes name="additionalServices" options=$additionalServiceList separator="<br/>"}
	            </td>
	            {else}
	            <td colspan="2" class="form_input">&nbsp;</td>
	            {/if}
	        </tr>
	        
	    </tbody>
	</table>
</form>